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Posts: 1443
Dec 11 08 6:06 PM
Some authors believe compensatory sweating to be more of a problem after treatment for axillary as opposed to palmar hyperhidrosis 9,23 . Gustatory sweating occurs on eating hot or spicy food. Its incidence varies from 1 per cent 20 to 51 per cent 9 , but it is generally underreported as both clinicians and patients do not view it as unduly troublesome. The exact mechanism is not clear. In the early days of open operations, Horner's syndrome was the hallmark of successful extirpation of the sympathetic chain, but this is now regarded as a serious complication. Comparison of its incidence in different series is made difficult by the different definitions of the syndrome used by authors. Mild Horner's syndrome may be marked by a miosis detectable only on close examination, but when severe ptosis is obvious. Temporary ptosis is Copyright 2004 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2004; 91: 264-269 Published by John Wiley & Sons Ltd Drawbacksof endoscopic thoracic sympathectomy 267 relatively common, perhaps as frequent as 1 per cent, but resolves over weeks or months. In the Japanese series the incidence of permanent Horner's syndrome was 0 ·3 per cent 13 . In an early series from Vienna the incidence was 3 ·5 per cent; this was attributed to thermal injury of the stellate ganglion because of the high level at which the chain was divided 24 . Rhinitis has been described by some authors as a consequence of ETS, with an incidence of up to 10 per cent 9 , but ETS has also been recommended as a treatment for chronic rhinitis 25 . These contradictory positions cannot be reconciled at present. Phantom sweating, a feeling of sweating (or blushing) without actual sweating, has also been reported as a sequela of ETS. It was first noted in patients undergoing open sympathectomy 26 . A number of cardiorespiratory effects have been associated with ETS. Occasionally patients complain of shortness of breath and of lethargy following sympathectomy. These features may be difficult to quantify but, in a small study of 18 patients, bilateral T2-4 ETS led to a reduction in resting and maximal heart rate but without effect on maximal workload 27 . The effect of surgery on bronchial reactivity is uncertain. Persistent bradycardia has been described after bilateral T2 sympathectomies. Permanent pacing was required in one patient 2 years after the procedure to treat persistent symptomatic bradycardia 28 . Other rare complications include abnormal suntanning and extensor policis longus paralysis 29 . Medicolegal aspects It is not surprising that significant medicolegal activity surrounds ETS. In the UK most operations are carried out by vascular surgeons. The Vascular Surgical Society of Great Britain and Ireland (VSSGBI) has audited medicolegal claims made during the period 1990-1999 30 . Of 424 claims identified, 12 followed ETS (W. B. Campbell, personal communication). There were three claims for postoperative pneumothorax (one of these also involved phrenic nerve damage). Three patients had not been warned of compensatory hyperhidrosis. A further three claims related to neuralgic complications (brachial plexus injury, intercostal neuralgia and paraesthesia). The final three involved Horner's syndrome, scarring and restricted movement, and (somewhat surprisingly) a fractured shoulder. One of the authors (A.E.P.C.) has previously reported four instances of injury on which he has given an expert opinion for legal purposes 31 . Two arose from double- lumen anaesthesia (one death and one brain injury), one was a successfully treated subclavian artery laceration, and one involved severe compensatory hyperhidrosis. Interestingly, only one of these appeared in the VSSGBI audit, suggesting that the medicolegal issue may be even greater than is currently appreciated. Comment This review reveals a striking similarity between reported series, the outcomes from small individual studies 20 being broadly similar to those of large reports
Some
authors believe compensatory sweating to be more of a problem after treatment for axillary as opposed to palmar hyperhidrosis
9,23
.
Gustatory sweating occurs on eating hot or spicy food.
Its incidence varies from 1 per cent
20
to 51 per cent
9
, but
it is generally underreported as both clinicians and patients do not view it as unduly troublesome. The exact mechanism is not clear.
In the early days of open operations, Horner's
syndrome was the hallmark of successful extirpation of the sympathetic chain, but this is now regarded as a serious complication. Comparison of its incidence in different series is made difficult by the different definitions of the syndrome used by authors. Mild Horner's syndrome may be marked by a miosis detectable only on close examination, but when severe ptosis is obvious. Temporary ptosis is
Copyright
2004 British Journal of Surgery Society Ltd
www.bjs.co.uk
British Journal of Surgery 2004; 91: 264-269
Published by John Wiley & Sons Ltd
Drawbacksof endoscopic thoracic sympathectomy
267
relatively common, perhaps as frequent as 1 per cent, but resolves over weeks or months. In the Japanese series the incidence of permanent Horner's syndrome was 0
·3 per cent
13
. In an early series from Vienna the incidence
was 3
·5 per cent; this was attributed to thermal injury of
the stellate ganglion because of the high level at which the chain was divided
24
Rhinitis has been described by some authors as
a consequence of ETS, with an incidence of up to 10 per cent
, but ETS has also been recommended as
a treatment for chronic rhinitis
25
. These contradictory
positions cannot be reconciled at present. Phantom sweating, a feeling of sweating (or blushing) without actual sweating, has also been reported as a sequela of ETS. It was first noted in patients undergoing open sympathectomy
26
A number of cardiorespiratory effects have been
associated with ETS. Occasionally patients complain of shortness of breath and of lethargy following sympathectomy. These features may be difficult to quantify but, in a small study of 18 patients, bilateral T2-4 ETS led to a reduction in resting and maximal heart rate but without effect on maximal workload
27
. The effect of surgery on
bronchial reactivity is uncertain. Persistent bradycardia has been described after bilateral T2 sympathectomies. Permanent pacing was required in one patient 2 years after the procedure to treat persistent symptomatic bradycardia
28
. Other rare complications include abnormal
suntanning and extensor policis longus paralysis
29
Medicolegal aspects
It is not surprising that significant medicolegal activity surrounds ETS. In the UK most operations are carried out by vascular surgeons. The Vascular Surgical Society of Great Britain and Ireland (VSSGBI) has audited medicolegal claims made during the period 1990-1999
30
Of 424 claims identified, 12 followed ETS (W. B. Campbell, personal communication). There were three claims for postoperative pneumothorax (one of these also involved phrenic nerve damage). Three patients had not been warned of compensatory hyperhidrosis. A further three claims related to neuralgic complications (brachial plexus injury, intercostal neuralgia and paraesthesia). The final three involved Horner's syndrome, scarring and restricted movement, and (somewhat surprisingly) a fractured shoulder.
One of the authors (A.E.P.C.) has previously reported
four instances of injury on which he has given an expert opinion for legal purposes
31
. Two arose from double-
lumen anaesthesia (one death and one brain injury), one was a successfully treated subclavian artery laceration, and one
involved severe compensatory hyperhidrosis. Interestingly, only one of these appeared in the VSSGBI audit, suggesting that the medicolegal issue may be even greater than is currently appreciated.
Comment
This review reveals a striking similarity between reported series, the outcomes from small individual studies
being
broadly similar to those of large reports
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